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Revenge of the Singh

Following in the footsteps of Jack-of-Kent and all good science geeks across the world, I’m afraid I cannot resist the opportunity for a Star Wars reference and, in the case of the recent events surrounding the BCA/Singh case, it even seems rather fitting.

We have an evil empire (the BCA) who with the help of a Dark Lord (Eady) dealt a significant blow to the forces of good (i.e. reason and free speech) and looked set to claim ultimate victory. However, as a result of the BCA’s actions we have now witnessed the growth of a loosely organised alliance of bloggers, science advocates, journalists and supporters of free speech who along with the tenacious rebel leader Singh are all beginning to take the fight back to the BCA.

Well maybe it’s not quite like Star Wars, maybe more like a Star Wars convention but still… it is true that the supporters of science, reason and free speech are now fighting back and are having quite remarkable success.

First, we have the ‘Keep Libel Laws out of Science’ campaign which drew significant support from many high profile figures, has been widely reported on and now has in excess of 10,000 signatures on it’s petition.

Second, we have the reporting in the mainstream media which in this case seems to have been of a rather high standard and also seems to have taken heed of the detailed information available from the blogs. The fact that it’s a journalist being sued for writing an article also likely has something to do with the sympathetic articles… that and Simon is in the right of course!

Third, we have the so called ‘Quacklash’ in which the skeptical and science blogging world has taken the BCA’s members to task for the ‘plethora’ of misleading and prohibited claims that are found throughout their websites and marketing material. The mass of complaints sent to various regulatory bodies has resulted in panicked e-mails from both the BCA and the McTimoney Association (the largest and second largest chiropractic associations in the UK) advising chiropractors to re-examine their claims, stop calling themselves doctors and take down their sites.

Fourth, we have the absolute demolition of the long awaited plethora of studies provided by the BCA in less than a day after it is released. The science bloggers again deserve all the credit here and for anyone who has yet to read the excellent reviews I strongly suggest doing so now (take a look through at the links at the bottom of the roundup).

And so it goes on…

I have not had time to do much blogging lately but my own small contribution to the good fight against the BCA’s quirky campaign of intimadition and silliness follows below:

Issues with the BCA’s ‘plethora’ of evidence

I thought it might be worth considering the studies the BCA replied and the critical analysis offered by bloggers alongside the short summaries of the evidence (or lack thereof) provided by Simon in his defence, which was made publicly avilable (thanks to Jack of Kent) back in November 2008. In it Simon summarised the lack of evidence for six ailments for which the BCA had promoted chiropractic treatments.

The BCA has accused Simon in their press statements of failing to address their evidence so let’s see if it’s true…

1. Colic

Nine studies listed in the plethora about colic. David Colquhoun and Ministry of Truth together provided a detailed analysis of the significant problems with each of these ‘studies’ (several are not even trials). MoT somewhat kindly recognised that “Wiberg et al. is perhaps the best designed of the three but still not without significant flaws” and then went on to explain such flaws in detail. Both writers also pointed to a recent well designed double blinded study, that the BCA failed to mention, by Olafsdottir et al (2001) which showed no discernible difference between a placebo treatment and the chiropractic treatment.

Now let’s look at what Simon said all those months ago (as summarised by Jack of Kent):

Simon Singh lists a number of trials where Chiropractic has been shown to be ineffective: Olafsdottir (2001), Ernst (2003), Husereau (2003), Ernst/Canter (2006).

He then provides a detailed critique of the Wiberg (1999) trial cited by the BCA, and in particular where it did not meet most of the standards required and expected of a properly-done clinical trial.

So Simon many months back mentioned better controlled and more recent trials/reviews which the BCA failed to address in their plethora and provided a ‘detailed critique’ of their best study…

And yet, it is the BCA’s contention that Simon failed to properly respond to their evidence…

2. Sleeping Problems

There are no trials looking specifically at sleeping problems instead there is one trial (Browning & Miller 2008) comparing two chiropractic treatments for infant colic in which the BCA’s summary mentions both treatments “offered significant benefits including increased sleep”. The problems with this study are discussed in the articles above examining the ‘evidence’ for chiropractic treatments of infant colic because thats what this study was theoretically designed to address.

The trial fails at being a useful study for it’s designated purpose but it doubly fails as evidence for chiropractic as a treatment for sleeping problems as it wasn’t examining this. So the BCA is attempting to use this one study as evidence for chiropractors ability to treat infant colic and evidence for their ability to treat sleeping problems but sadly it shows neither as it is not blinded and has no control group. Also of note is that this study was published after the original article was publishedso how Simon is expected to have consulted it is beyond me!

So Simon’s summary that:

Simon Singh is unaware of any published clinical trials investigating (let alone supporting) the efficacy of Chiropractic in dealing with sleeping problems.

He points out that the BCA’s reference is to a page in a book (Anrig & Plaugher) discussing two case reports.

Is entirely valid. The BCA has provided no such trials.

3. Feeding habits

Here we have a similar situation to the evidence for treating sleeping problems there are no trials specifically looking at chiropractic treatments to improve infant feeding habits and indeed none of the BCA’s comments even make reference to trials improving feeding habits. It’s likely that as with sleeping problems the BCA has found one or two trials looking at another topic in which the parents reported the child had improved eating habits and thus decided that chiropractic treatments are therefore proven to help with this problem. The issue here is once again that there are no trials looking at the topic specifically and that none of the other trials provided are of a high enough quality to draw such conclusions.

So once again Simon’s summary seems entirely fair:

Similarly, Simon Singh is unaware of any published clinical trials investigating (let alone supporting) the efficacy of Chiropractic in dealing with feeding problems.

He points out that the BCA’s reference is to a page in a book (again Anrig & Plaugher) discussing feeding habits of parents, with no research or evidence.

4. Frequent Ear infections

Four studies in amongst the plethora which mention ear infections. Gimpy demolishes three of these studies and in particular points out that none include control groups (and one is actually about osteopathy). The fourth (Hawk et. al 2007) is simply a review which includes as the kind of poorly controlled and poorly conducted studies that we see throughout the rest of the plethora and as such it’s conclusions are rather hard to take seriously.

Anyway again back in November we find that:

Simon Singh is also unaware of any published clinical trials investigating (let alone supporting) the efficacy of Chiropractic in dealing with frequent ear infections.

Well it seems that Simon was not aware of at least two of the studies mentioned by the BCA however it is only in the very loosest sense that they can be have said to have ‘investigated’ the efficacy of anything. If these studies amount to the best evidence the BCA can muster for chiropractic treatments of ear infections then I think Simon’s statements remain quite well justified. Extremely poorly designed studies with no control groups do not amount to evidence for efficacy.

5. Asthma

Five studies relating to asthma. One is the systematic review discussed above, one is a letter to an editor, two are looking at osteopathic manipulations and the one remaining study is a seriously flawed pilot study. All of these have been dealt with in detail over at Evidence Matters but the point worth emphasising is that the BCA only managed to produce ONE study relating to chiropractic treatments for asthma and even that only claims to be a pilot study.

Meanwhile:

Simon Singh lists a number of trials where Chiropractic has been shown to not be effective: Balon/Aaker (1998), Balon/Mior (2004), Hondras (2005) and Ernst/Canter (2006)

He then points out that the BCA’s citation (Kukurin) is to a letter to the editorcommenting on a pilot study.

Note that again Simon had already pointed out to the BCA the problem with citing a letter to an editor and yet the BCA continues to attempt to use it as evidence for it’s case. As for Simon’s citations:

– Hondras (2005) is a Cochrane review which found that there was not enough evidence from trials to show that ANY manual therapies help asthma.

– Balon / Aaker (1998) is a randomised, blinded and placebo controlled trial available on pubmed that concluded that “In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.”

– Balon / Mior (2004) is a review assessing the evidence for chiropractic care in the management of asthma again it is available on pubmed and features the following conclusion “There is currently no evidence to support the use of chiropractic SMT as a primary treatment for asthma or allergy.”

– Ernst / Canter (2006) is a review of the reviews for spinal manipulation as an effective treatment of any condition. Unsuprisingly the review is easily found on pubmed and concludes that the data examined does “not demonstrate that spinal manipulation is an effective intervention for any condition.”

Compare and contrast the quality of sources and you get a hmmm…

6. Prolonged Crying

One ‘study’ in the plethora specifically mentions ‘excessive infant crying’ and the ‘study’ is not even actually a study but simply a proposal for “a framework for chiropractic care”. Presumably the BCA would also argue that there is evidence in the studies that look at other topics that prolonged crying can be reduced but once again this argument would fall flat on it’s face because the other studies are of such a poor quality that drawing wider conclusions from them is just not warranted.

So once again Simon’s assesment seems entirely justified although at least in this case they seem to have dropped the Budgell source that he criticises:

Simon Singh is also unaware of any published clinical trials investigating (let alone supporting) the efficacy of Chiropractic in dealing with prolonged crying.

He points out here that the BCA’s citation is to a non-publicly available paper (Budgell) which looks at the experience of chiropractors and does not look at clinical trials.

And Finally…

So there you have it. The BCA’s plethora of evidence is, as everyone expected, extremely underwhelming. Simon’s original responses offered many months previously also seem to hold up perfectly fine in light of the BCA’s ‘evidence’ despite their claims to the contrary. Perhaps, the compilers of the plethora would have been well served to refer to Simon’s discussion of what counts as good quality evidence contained in his defence back in November 2008:

In brief, the essential features of a high quality trial are:

a) a control intervention that allows an unbiased comparison and conclusions about the scientific effects of the tested intervention per se (rather than non-specific factors such as additional therapeutic attention, for instance);

b) a sufficiently large number of patients to minimise random biases;

c) blinding of patients and those evaluating the results of the tested intervention to minimise expectation bias; and

d) random assignment of patients to a control group or treatments group, to minimise selection bias.

Evidence from poor quality trials is not scientifically reliable and may be worse than no evidence at all, as it has a tendency to be overly positive and might therefore be misleading in suggesting that an intervention is effective when it is not. Case studies, case reports, case series and uncontrolled trials do not constitute evidence/reliable scientific evidence.

Taking such things into account I think the ‘plethora’ quickly reduces itself into less than ‘a jot’.

Clearly the BCA are a bunch of manipulators. Noun: ‘A person who handles things manually’. How do they propose to treat themselves for Sleeping Problems and Prolonged Crying? #
For surely by now they must be suffering from those conditions. If they are not, then the cheques in the post. I’ll bet you couldn’t insert an American Express Card between the cheeks of their arses. They didn’t shoot themselves in the foot with this one they shot themselves in the head. I hope they have massive mortgages on their mansions and they are reduced to penury.

This is a wonderful post. Mr Kavanagh, could you write to the BMJ with a summary of this post? Richard Brown of the BCA has written to them with his list of “evidence” and someone should write a response debunking his claims: http://www.bmj.com/cgi/eletters/338/jun03_1/b2254

I think all the science bloggers who have critiqued the BCA’s evidence should write to the BMJ on this.

As a Practicing Chiropractor I find myself frustrated by the quality of the remarks by those who consider themselves sceptical. A questioning mind is healthy and had it not been so I would not be practicing as a chiropractor now.

Having completed a degree in Biomedical Sciences prior to commencing a 5 year degree in Chiropractic, I like many other scientific minds continue to understand the importance of the scientific method, having written a number of experimentally based dissertations myself. Having the ability to demonstrate, through well defined research the efficacy of your subject matter has a truly beneficial part to play in the advancement of science as a whole. However, it is only a part, and like many other approaches carries its own flaws. Chiefly among these is the vested interest of the party funding research studies.

Sadly, we do not live in an ideological scientific world. If we did the truth, true scientists aspire to would not be capped, cut off or partially published by financially driven enterprises that seek only to provide results which further their particular interests. As any practicing scientist will tell you this tends to be the greatest bug bear when submitting research proposals. Whether we like it or not, research is an expensive business, and if your particular research is not likely to line the pockets of those funding you it is simply not likely to happen.

But what about the scientific method! Well it doesn’t apply to medicine so why insist it apply to us! How many untried and untested surgeries are carried out everyday without a shred of evidence to support them. When we do have the evidence, examine it! Spinal fusions or laminectomys carry an 80% FAILURE rate, with either no change or worsening of presurgical symptoms, set aside the risks associated with surgery itself and anaesthesia. Create hypothesis, test hypothesis Chemical A + Chemical B = Chemical C repeat and get the same results for eternity. That’s the scientific method. Give 10 people with a headache an aspirin and sit back and watch the diversity! Replace aspirin with any drug, surgery or physical intervention the results will always be different because of the 1000’s of variables which make up the human bodily functions. RCT’s, statistics, P values of course can be manipulated to say whatever the financial backer wants them to say. What about advertising standards? Have we all seen the advert for the painkiller that targets the site of the pain! Now how does it do that, does it have a little brain! Oh well, everyone knows its just marketing and it really blankets everything. That’s ok then! How do they get away with it? Money! Money! Money! What about the safety issue with Chiropractic. Sinister risks with chiropractic are incredibly rare with incidences suggested at 1 in 500,000 to 1 in 3million. In perspective iatrogenic death (or death caused by or resulting from medical intervention or advice) is now estimated as the third highest cause of death in the US.

Why I mention this is two fold. Firstly there are only 2 ECCE (European Council on Chiropractic Education) accredited Chiropractic schools in the UK. Primarily research is carried out at the University level. Here each school has approximately 300 students per year all of whom are required by statutory regulation to carry out a research dissertation as either an experimental study, or a literature review. Sadly although excellent and compelling work is produced, as is the case in the hundreds of universities across the land very few are published and therefore cannot qualify as recognisable research. Mine for example studied the effect of chiropractic adjustments of the cervical and upper thoracic spine upon patients’ hearing. The hypothesis setting out to either confirm or question DD Palmers original finding of restoring Harvey Lillards hearing. My test subjects were patients receiving chiropractic care at our teaching clinic. Every patient tested via recognised audiometric testing had no diagnosed hearing complaint. My findings showed that a significant number of patients had markedly improved hearing following an adjustment. This was in comparison to my control group that only received chiropractic adjustments below the level of T4. This group showed little or no change post adjustment. In addition a follow up study showed that this improvement had sustained at their next scheduled appointment.

Although I followed the scientific method and provided reproducible results, having not had my findings published in a peer reviewed journal they are inadmissible to the current available research. Of course, my failing was to submit my findings, however how many students across the land submit quality research which never finds its place in a periodical. Sadly, just as doctors attend medical school to help maintain and restore life, Chiropractors attend college to help improve, maintain health and potentially prevent future problems. Neither attending college to become research scientists. Luckily for medics there is an entire infrastructure dedicated to medical research, not so for chiropractic.

Here lies the flaw. According to UCAS there are currently 325 Institutions in the country providing degree level studies. My Biomedical Sciences year had 200 students alone. Examining studies funded for medical or scientific research often find their beneficiaries in the lucrative pharmaceutical industries. This is in itself not a bad thing. It off course allows for the continuing advances in medicine that allow for wondrous interventions when critically needed.

Therefore of the 325 Institutions there are thousands of students and scientists creating, experimenting and publishing many thousands of articles, which helps expand our medical knowledge and generates further study.

Examine chiropractic research in comparison, still as costly but as can be seen from the sceptics still as important. Now question where this research in the vast quantities requested is to come from. Whether believed or not, Chiropractic has been seen to help many different age groups with a host of different complaints, using a natural, non-invasive technique that does not require the prescription of any pharmaceutical. Are these companies likely to bend over backwards to fund the research. Sadly and unsurprisingly not. Equally are there hundreds of universities throughout the land with large Chiropractically interested students writing, and publishing chiropractic research. Again sadly not. What research exists, currently sits unpublished on chiropractic library shelves. Is this anyone else’s fault. Off course not. Just because these copious studies are not published doesn’t mean chiropractic does not work it simply means we as a profession need to work harder at publishing.
I am not intending to make excuses for our weaknesses as a profession but suggest that even with our failings chiropractic continues to help and improve the quality of life of many thousands of well educated patients who attend our clinics daily despite limited research.

In addition, many sceptic bloggers make the claim that chiropractic targets the weak and vulnerable.

Although one of my biggest complaints by patients is that chiropractic care, as a private health care, can be expensive and is (until recently via the NICE guidelines) unavailable on the NHS and is therefore appearingly unattainable by the aforementioned weak and vulnerable it certainly insinuates that chiropractic patients simply do not have the intelligence to make an informed decision and are somehow being manipulated into starting care.

This could not be further from the truth. Ironically the vast majority of patients attending our clinics for their initial consultation carry with them equally sceptical minds, filled with articles such as these as well as the preconceptions of their friends and families, having often exhausted all other avenues. In fact they are basically primed not to believe a word we say. Nevertheless If chiropractic is found to be a course of action that might benefit the patient, full explanations are given and treatment, with consent begins. There is no talk of mysticism as some bloggers may have you believe, just a simple straight forward explanation as to how our bodies and our nervous systems function in relation to the presenting complaints. If of course chiropractic is not a viable course of action, our training in diagnosis enables us to make the relevant referral with the correct expediency.

Among my patient base alone I have Nurses, Midwives, GP’s, Consultants, Lawyers, Service men and women, Lecturers, Managing Directors and Professors. Not classically thought of as ‘weak and vulnerable’. Further still, these same individuals not only have achieved relief from their symptoms they have chosen to continue to maintain these improvements, in most cases, over years. Do I go to their houses and drag them into my clinic each month, do I hound them with marketing material until they relent. No. patients choose what is best for them. Do they consider being labelled weak and vulnerable, worse still ‘brainwashed’ by a small minority offensive. Of course.

Naturally, journalists and scientists are supposed to present the news and results in an unbiased fashion. But then that wouldn’t sell! Ask us to work harder as a profession to solidify our foundation of research and subscribe to the recognised standards but please do not insult the integrity and intelligence of our patients along the way

Finally I am often asked whether I agree with the BCA’s approach to the case with Simon Singh. As a scientific journalist it is absolutely fundamental that Simon should question the validity and efficacy of any therapeutic intervention, including, of course, chiropractic. Not to do so would not advance scientific knowledge. However to label something as ‘bogus’ simply through limited investigation overstepped the professional mark. Doing so allowed him to join the ranks of fellow eminent scientists who vilified anyone who suggested the earth was round and that we were not the centre of the universe! His support is admirable, but personally I feel once further study is completed and evidence comes to light that indeed chiropractic does help those suffering many different complaints, he may have benefited from saying that ‘although there is a lack of compelling evidence to the standard required by our current western medicine, although anecdotal, it appears chiropractic may have, a currently poorly understood effect on a number of conditions, however I will continue to have reservations until a better quality of investigation is carried out.’ His choice of language is what has infuriated many within the profession, and has led to the situation being what it is. Is it ideal, no! could the money have been better spent on research? yes. But defending oneself against such comments is not just to protect chiropractic but also the many educated and infuriated patients who both benefit from and will continue to benefit from chiropractic care.

Jon your response is very long so I’m afraid I’m not going to be able to offer a response to all the points you made or at least not right now but I’d like to address some of the arguments you make.

1: I think your comparison with calling chiropractic treatments for non-back related ailments in children ‘bogus’ to arguing that the earth was flat and that sun orbited the earth is absolutely ludicrous.

Anyone advocating any treatment could make the same kind of claim and it would be equally meaningless: ‘You don’t think my magic wand cures people of cancer? Well your just like those people who refused to believe the world was round!’ Simon is not denying compelling evidence he is in fact doing the opposite, he is respecting the conclusion that the current evidence leads us to. Your suggestion that he hasn’t surveyed the current evidence thoroughly is also completely contradicted by the fact that the studies he discussed in his book and in his response, as demonstrated above, are of a much higher calibre than than studies that it took the BCA 15 months to reveal.

2: Promoting treatments for childhood ailments is to an extent targeting a vulnerable population i.e. worried parents. Now I do agree that those who visit chiropractors, by and large, do so of their own volition because they believe in it and find it helpful. And yes certainly many supporters of chiropractic will be intelligent and perfectly capable folk. I don’t think that anyone is actually disputing this. You accuse critics of chiropractic of condemning chiropractors clients but in actual fact the main target of all the criticism has simply been the marketing material of chiropractors. This is to my eyes a perfectly legitimate aspect to criticise and does not entail calling everyone who visits a chiropractor stupid.

3. You arguments concerning the lack of evidence for certain mainstream treatments are I think over exaggerated. As proving to be more effective than a placebo is a basic requirement for a mainstream medicine and while it is true that treatments have in some instances been later found to be a placebo when this has occurred it is generally big news and they are no longer used. I wonder if this has EVER happened in the history of chiropractic? If there are any treatments previously considered effective that have later been studied and found to lack evidence and be removed… I sincerely doubt it. Also, while pain killers, for instance, may indeed have a variable effect on certain individuals the studies have been done and it’s been proven that they produce an effect beyond the placebo. This is not the case for chiropractic treatments of non-back related ailments.

However, even if we accept all your points and agree that mainstream medicine has treatments which are not supported by good evidence. This does not help validate chiropractic treatments. Indeed, I think it simply further illustrates the need to constantly evaluate the evidence basis for medical treatments. It does not mean that we should simply accept chiropractic as equally valid and stop worrying about the evidence.

4: As for your suggestion that there is tonnes of excellent evidence unpublished and unheeded for chiropractic treatments effectiveness in treating non-back related issues. This seems extremely unlikely to me for several reasons:

a) The chiropractic university courses are not generally noted for their thorough grasp of the scientific method. And indeed as these studies show even very basic controls are often not included by practicing chiropractors. So suggesting that studies carried out by student chiropractors are of a very high quality seems like a rather questionable claim to me. If the chiropractic students produce such great studies why can’t chiropractors do the same?
b) The BCA which is a chiropractic organisation supposedly dedicated to evidence based medicine has in publishing it’s ‘plethora’ made it abundantly clear that the quality of studies that chiropractors find compelling is extremely low. Better quality studies with negative results are also apparently ignored.
c) If what you claim was true it makes no sense that the findings of all those chiropractic dissertations would not be replicated in the better controlled studies that have been conducted. If the effect is real then better controlled studies should be seeing this instead the clear pattern we see is better controls = more negative results.

I could go on. But in general your post boils down to a long example of special pleading. It is basically one long argument trying to sidestep the problem which is central to this whole issue: There is no good evidence that chiropractic medicine can cure ailments other than back pain. This is what Simon Singh was criticising and this is what the BCA has failed to present in it’s ‘plethora of evidence’.

I would also add that if the BCA’s goal was to protect it’s reputation then it would have been better served by writing a response in the Guardian as offered. It would have saved everyone involved time and money and would have prevented the chiropractic profession from gaining the reputation of responding to criticism with legal threats instead of evidence.

You make so many points that I cannot reply to them all. Let me address your comment that “if your particular research is not likely to line the pockets of those funding you it is simply not likely to happen”. I have been a practicing research scientist (unlike you, if I interpret correctly). My research was funded by the Research Councils, charities, and learned bodies (such as the Royal Society). In no case was it ever likely to line the pockets of the funders. Nor was this ever my motivation, which was to do the best science possible, and to help alleviate suffering. This was particularly the case in charity funded research, where I had the privilege of meeting both sufferers and charity workers.
It is not true to say that only developments which are likely to lead to a pharmaceutical solution are funded. Hearing loss is a good example. There is considerable research into hearing loss and its causes, because hearing loss carries considerable economic costs both for the sufferer and society. A variety of new techniques are now available, particularly cochlear implants, and advances continue to be made. If there were plausible evidence that spinal manipulation were effective, then it would have a reasonable chance of funding.
Ask yourself this question, honestly. Are you at risk of saying “Evidence does not support my beliefs, therefore evidence is corrupted/wrong/inappropriate”, rather than “Evidence does not support my beliefs, therefore my beliefs require re-examination?” Humans are notoriously bad witnesses in self-reporting illness, which is why we developed the double blind randomised controlled trial: to stop us fooling the most gullible person in the room – ourselves. Was your experiment designed to disprove your hypothesis? Was it randomised and double blind as well as controlled? Could you have observed what you wanted to observe?
The BCA presented a ‘plethora’ of evidence. How would you rate the quality of this evidence? If no good quality evidence is available for a potion or practice, honestly, should it be sold to parents as if it were?

I am a practicing chiropractor with some research experience, albeit minimal. I find the tennor the discussions intriguing. This is because I fail to see why there is such an emotional charge about the whole issue, particularly to those who appear to have no involvement in the issues at hand. When I see such a response to a reasonable explanation as Jon C I wonder is it that people are “counting coup” or is there an ulterior motive.

I know mine is that I have worked with patients for 28 years and have never advertised or promoted myself in any way that I could not substantiate through the evidence, most usually the best evidence was patient outcome to care. Over the years it became interesting to me when patient coming in for low back or neck pain would remark that some other non-musculoskeletal issue resolved, but I just chalked that up to coincidence.

When I attended chiropractic college I had never been to a chiropractor and was extremely skeptical. The fun for me as a pracitioner is being skeptical at all times but also trusting my feelings which are difficult to quantize. This is similar to quantitative versus qualitative chemical analysis. The qualitative part leads to the “art” of chiropractic whereas the quantitative portion to the scientific aspect.

For me the main issue that seens to be glossed over is that most healthcare interventions offered by clinicians have a limited evidence base of high level research. That is why the term evidence based practice is coming into vogue. With evidence based practice we see that included in a clinical decision is the doctor’s experience which incorporates the multifactorial unique nature of each and every patient.

With the limited nature of most healthcare evidence a higher level of stress should be placed upon risk benefit ratios. I do know that determining benefit can be a difficult path to walk since no chiropractic adjustment sham has been properly validated and it is hard to blind a patient and doctor from the chiropractic treatment process.

However risk can be readily identified and comparisons can be made of patients who have head, neck and low back pain and compare the alternatives, which is not usually doing nothing. What are the associated risks with medication or other more invasive procedures?

What about non-musculoskeletal complaints and chiropractic care? If the risk of a procedure is low, the patient has attempted other interventions and are not willing to either accept the associated risks, side effects, or choosing to do nothing, then some alternative with low risk might be worth investigating. The question involves then how much evidence and what level of evidence is necessary for a patient to attempt a low risk intervention such as chiropractic for a non-musculoskeletal condition?

I do not believe that every child with colic, bed wetting, sleep disturbances or whatever need chiropractic care or would systematically benefit. But I do believe that clinically significant percentage would. The difficulty is getting the research community to embrace this type of study and like Jon C noted the pharmaceutical community and those outside of chiropractic are not interested. Developing a clinical prediction rule for patients with non-musculoskeletal complaint that could be treated by chiropractors would be an intriguing study.

I have found, not exclusively, that some patients who have a physical trauma associated with a non-musculoskeletal complaint sometimes will have their non-musculoskeletal complaint resolve as they receive treatment for their physical trauma. That might be one factor that could be utilized in differentiating patients. But the issue is that the ratio of patients with non-musculoskeletal complaint helped by chiropractic care would be low and that would mean a large sample for a study would be needed for it to generate worthwhile information.

Does anyone know how much funds it would take to coordinate such a study? Who is willing to take it on? Wouldn’t it be something a government would want to investigate for its people? A relatively low cost, low risk procedure for a subset of patients suffering from various non-musculoskeletal complaints would save money and improve general public health. I know I would be happy to volunteer my time to be part of this study. I like most of my chiropractic colleagues just want to help our fellow man (and woman) and would love to have more information, research, and answers to help guide us.